Insomnia

Insomnia is a disorder characterized by difficulty initiating sleep, maintaining sleep, or experiencing non-restorative sleep, occurring at least three nights per week for at least three months and producing daytime impairment. Acute insomnia (less than three months, often triggered by stressor or environmental change) is common and typically self-limited. Chronic insomnia affects 10-15% of adults and often involves hyperarousal, cognitive patterns that maintain the disorder, and circadian factors.

Cognitive behavioral therapy for insomnia (CBT-I) is the first-line evidence-based treatment, consistently outperforming pharmacological interventions in long-term outcomes. Components include sleep restriction, stimulus control, cognitive restructuring around sleep-related thoughts, and sleep hygiene education. Effect sizes are large (SMD 0.8-1.2 for sleep onset latency and sleep efficiency) and benefits persist after treatment ends, unlike medication-based approaches. Digital CBT-I programs have comparable efficacy to in-person delivery.

Supplement interventions are appropriate as short-term adjuncts or for patients declining CBT-I. Acute sleep onset agents include low-dose melatonin (0.3-0.5mg, 30-60 minutes before intended sleep), apigenin 50mg, and L-theanine 200mg. Chronic sleep quality agents require 2-4 weeks of consistent use: magnesium glycinate 300-400mg elemental nightly and glycine 3g pre-bed. Avoid high-dose melatonin (3-10mg) for chronic use because it suppresses endogenous production. Avoid diphenhydramine-based OTC sleep aids in elderly patients due to anticholinergic cognitive effects. Screen for sleep apnea in snorers and in individuals with non-restorative sleep despite adequate duration.